Is there anyone out there that would be willing for share your E/M note with us. Pt info removed of course. We need to do a better job at notes and we want to compare ours to others who have a really strong e/m note. Anyone willing to share? Fax or e-mail would be fine. Fingers crossed I find a kind soul to help. thank you
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Wiki 99213-99214 E/M Note
- Thread starter bill2doc
- Start date
We just want to be sure we have everything we need on our e/m note. ThanksJessim929
Guest
As long as you have a clear HPI, history/ROS/physical exam as medically pertinent (important if you participate in MIPS) differentiate your ailment(s) - using chronic stable, chronic w/ exacerbation, acute uncomplicated, undiagnosed new, etc. (to make it easier on your EMR), clearly note any data you used - films reviewed, outside records reviewed, any tests ordered, and document your MDM - even if you detail the risks/benefits/alternatives to treatments and the patient defers or declines and that's documented, it counts as if the patient opted for it. And remember: starting/stopping/changing a dose/continuing with refills on any prescription counts as Rx management.